Is ordering a chest x-ray with a first episode of wheezing common practice?

“Yes”­ is the answer to this question, according to results of a survey targeting pediatric emergency medicine (EM) and general EM attending physicians. However, fewer pediatric residency-trained physicians (26%) routinely obtain a chest x-ray (CXR) than EM residency and other residency-trained physicians do (54% and 68%, respectively). ­The survey of 552 clinicians showed that fellowship training, resident supervision, years of independent practice, and practice location also influence the likelihood of routinely ordering a CXR in children who present with a first episode of wheezing.

The anonymous questionnaire included 14 closed-ended and free-text questions designed to elicit respondents’ demographic characteristics and their belief and current practice of getting a CXR in children experiencing a first episode of wheezing. About half (54%) of respondents were from EM, 42% from Pediatrics, and 4% from other residency-training backgrounds. Most (58%) had practiced for fewer than 5 years and were board eligible or board certified in pediatric EM.

Of the about one-third of attending physicians who obtain a CXR in patients having a first episode of wheezing, 81% indicated that they believe it is the standard of care. Thirteen percent reported that they routinely obtain a CXR only for children younger than a certain age, which ranged from 2 weeks to 12 years (median age of 1 year). Physicians who do not supervise residents in their practice were most likely to obtain a CXR routinely as were those with 5 or fewer years of experience. In addition, practicing in suburban and rural areas and in parts of the country other than the Northeast was associated with higher use of routine CXR.

The researchers noted that recent studies have concluded that a CXR is not routinely indicated in children presenting with a first episode of wheezing and pointed out that reducing unnecessary radiographs will lower care costs and increase emergency department efficiency as well as decrease these children’s exposure to radiation (Patel NH, et al. Pediatr Emerg Care. 2020;36[1]:16-20).

Thoughts from Dr. Farber

It has not been the standard of care to order a CXR for first episodes of wheezing for some years (Ralston SL, et al. Pediatrics. 2014;134[5]:e1474-e1502), but old habits die hard, particularly if access to an x-ray machine is easy, as in an emergency department. We also need to do a better job of getting the word out about not using albuterol for bronchiolitis, as indicated in the above clinical practice guideline.